Question

A nurse inadvertently administers the wrong dose of antibiotic to a patient recovering from surgery. Which of these is the correct course of action for the nurse when documenting this in the patient's medical record?

A. The nurse should just document the dosage given in the patient's chart. An incident report is not necessary because it was simply the wrong dosage of a drug that was ordered.
B. The nurse should create an incident report and include a copy of the report in the patient's medical record.
C. The nurse should tell the patient of the incident and ask his or her preference on if an incident report should be created and if one is, it should be included in the patient's medical record.
D. The nurse should create an incident report and record the facts of the incident in the medical record, but does not have to include an actual copy of the incident report or reference its existence.

Answer 1

The nurse should create an incident report for internal use and document in the patient's medical record the actual dose of medication given without including or referencing the incident report. Disclosing the error to the patient should be done based on facility policy.

Step-by-step explanation:

When a nurse administers the wrong dose of an antibiotic, the proper protocol is to ensure that patient safety has not been compromised and to follow healthcare facility policies for incident reporting. The nurse should first assess the patient's condition and notify the physician as required for any necessary interventions. Following patient care, the nurse must then create an incident (or variance) report detailing the event. This report is for the healthcare facility's internal use to improve practices and prevent future errors and is usually not included in the patient's medical record.

However, it is crucial for the nurse to accurately document in the patient's medical record the actual dose of medication administered, the time, the route, and any observed effects or actions taken following the error. It is important to document the facts without making subjective or judgmental statements. Disclosure of the incident to the patient should be done in accordance with the healthcare facility's policy and ethical guidelines, keeping the patient informed about their care. It is best practice not to reference the incident report within the patient's medical record.